Original Article
Iran J Public Health, Vol. 47, No.4, Apr 2018, pp.519-530
The Risk Factors Affecting Survival in Colorectal Cancer in Taiwan Chao-Hsien LEE 1, Shu-Chen CHENG 2, Hong-Yi TUNG 1,3, Shih-Chang CHANG 4, Ching-Yun CHING 5, *Shu-Fen WU 1,5,6 1. Dept. of Health Business Administration, Meiho University, Pingtung, Taiwan 2. Dept. of Cancer Registry Division, Cathay General Hospital, Taipei, Taiwan 3. Dept. of General Surgery, Yuan’s General Hospital, Kaohsiung, Kaohsiung, Taiwan 4. Dept. of Colorectal Surgery, Division of Surgery, Cathay General Hospital, Taipei, Taiwan 5. Dept. of Nursing, Yuan’s General Hospital, Kaohsiung, Taiwan 6. Dept. of Nursing, College of Medicine, I-Shou University, Kaohsiung, Taiwan *Corresponding Author: Email:
[email protected] (Received 04 Sep 2016; accepted 15 May 2017)
Abstract Background: Colorectal cancer is one of the most common malignancies in developed countries. The incidence of colorectal cancer (CRC) in Taiwan is rising. We aimed to determine the five-yr survival rate of patients diagnosed with CRC and determine factors affecting survival. Methods: All patients were identified from the Taiwan Cancer Data Base of the Medical Center Hospital in North Taiwan from 2007 to 2013. Data were collected using medical records and the cancer database. In all, 869 patients with CRC were included. Survival analysis was performed using Kaplan-Meier curves, and differences between the curves were analyzed using the log-rank test. Cox proportional hazards regression models were used to analyze survival by each variable. Results: The five-yr survival rate and the mean survival time after cancer diagnosis were 68.7% and 71.27±1.27 months. Perineural nerve invasion, distant metastasis, age, pathological differentiation grade, obstruction and regional lymph node metastasis were found to be independent predictors of the survival and prognosis of patients with CRC. Conclusion: Perineural nerve invasion was an important factor related to the survival of CRC patients. Thus, the earlier detection of CRC might help improve survival. Keywords: Risk factors, Survival, Colorectal cancer
Introduction Colorectal cancer (CRC) is the second and third most commonly diagnosed cancer type in females and males, respectively, representing almost 10% of the global cancer incidence. These estimates correspond to age-standardized global incidence and mortality rates of 17.2 and 8.3 per 100000, respectively (1-3). There have been slightly more
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incident cases and deaths among men than among women in most parts of the world, except in the Caribbean (4). The reported incidence of CRC is highest in developed countries, including the United States, Canada, Australia, northwestern Europe, Japan, South Korea, and Singapore. However, the incidence and mortality
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Lee et al.: The Risk Factors Affecting Survival in Colorectal …
rates for CRC are higher in Japan, South Korea, Singapore, China, Hong Kong, Taiwan, and Thailand (5-7). In Taiwan, more than 15410 new cases of CRC were diagnosed in 2013. The incidence rate of CRC is 44.32 per 100000, and the mortality rate is 14.7 per 100000 in both sexes per year (8). CRC imposes a considerable social economic burden, which includes direct medical care (e.g., treatment by stage at diagnosis, type of cost and disease phase), nonmedical costs, and productivity loss. Cancer survival is an indicator of the overall effectiveness of health services in the management of patients. The five-yr survival rate of individuals with CRC was 65% in the United States. The five-yr survival rate of stage I and II CRC ranges from 80%-90%, whereas stage III and IV metastatic diseases are associated with five-yr survival rates of 60%-71% and 8%-13%, respectively (9,10). Currently, in Taiwan, the overall five-yr survival rate of CRC is 63.0% (11). The five-yr survival rate was 74.3% for stage I CRC compared with 76.6% for stage II, 56.6% for stage III and only 16.7% for stage IV (12). The lifetime cost usually increases with advanced stages. The average cost of CRC in Spain, Iran, and Malaysia was 20.298€, $10715, and RM 13622 for stage I, 28.251€, $1592, and RM 19752 for stage II, 36.8948€, $1642, and RM 24972 for stage III, and 27.001€, $16723, and RM 27377 for stage IV, respectively (7, 13, 14). In Taiwan, the average cost of treating CRC in $/per year was $8416 for stage II, $14334 for stage III, and $21837 for stage IV, indicating large savings with early diagnosis and treatment (6). CRC is considered primarily a “lifestyle” disease. Demographic variables, such as age, gender, familial CRC history, diets high in calories and animal fat, alcohol consumption, and obesity, in addition to other factors, such as tumor site, size, grade, histologic type, TNM stage, and carcinoembryonic antigen (CEA) level, have all been found to significantly affect survival in CRC (3,15-19). In the present study, we used population-based data from the Taiwan Cancer Data Base of the medical center hospital in North Taiwan to compare socio-demographic and cliniAvailable at:
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cal pathological characteristics, prognostic factors, and overall survival among 3 groups of CRC patients, i.e., those surviving 12, 36, and 60 months. This study aimed to explore the survival rate and the potential factors influencing survival among CRC patients in northern Taiwan.
Materials and Methods Study population
We conducted a single-center, retrospective cohort study to estimate the survival outcome of patients diagnosed with colorectal carcinoma at Cathay General Hospital in North Taiwan from 2007 to 2013. Data were extracted from medical records and the cancer database by trained data collectors. The eligibility criteria included the following: diagnosis and treatment of CRC; the International Classification of Disease for Oncology, 3rd Edition (ICD-O-3) topographical codes of C18.0-C20.9 (excluding C18.1) and morphology codes of 8000-8152, 8154-8231, 8243-8245, 8247-8248, 8250-8576, 8940-8950 and 89808981. Participants who showed more than one type of cancer, ICD-O-3 morphology codes of 8935-8936, 8153, 8240-8242, 8013, 8246, 8249 and 9590-9720, a TXNXMX stage of 888 or 999, metastasis to the brain, or a survival time of fewer than six months were excluded. Demographic data extracted included gender, age at diagnosis, body mass index (BMI), smoking history, betel nut chewing status, drinking habits, and date of last contact or death. The evaluated tumor characteristics included primary site, histologic type, grade/differentiation, and size, as well as treatment type and regional lymph node or distant organ metastases. The disease staging was based on the American Joint Committee on Cancer (AJCC) criteria; cancer site-specific factors included CEA, circumferential resection margin (CRM), tumor regression grade, perineural nerve invasion, KRAS mutation, obstruction, and perforation. Survival data were obtained using death and date of last contact records to determine the current situation or date of death of each patient.
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Iran J Public Health, Vol. 47, No.4, Apr 2018, pp. 519-530
The study was reviewed and approved by the hospital’s institutional Review Board (No. CGHP104060). Statistical analyses were performed using SPSS software (ver. 22.0, Chicago, IL, USA). Quantitative values were compared using t-tests for independent groups. Categorical data were analyzed using the χ2 test or Fisher’s exact test. Survival probabilities were estimated at intervals of 12, 36 and 60 months from the date of diagnosis to the date of death. Survival curves were constructed using the Kaplan-Meier method, and differences were analyzed by the log-rank test. Cox proportional hazards regression models were used to analyze survival by each variable. The level of
statistical significance was set at P
